Cardiovascular risk factors in adolescents with prediabetes.

AIMS: Adolescents with Type 2 diabetes are more likely to have cardiovascular disease (CVD) risk factors but there are few data available among adolescents with prediabetes. We characterized CVD risk factors among adolescents with prediabetes in the USA and compared levels of those risk factors with adolescents with normal glucose. METHODS: The 2005-2014 National Health and Nutrition Examination Survey, a nationally representative cross-sectional survey, included 2843 adolescents aged 12-19 years after excluding those with diabetes. Prediabetes was based on an HbA1c , a fasting plasma glucose or a 2-h plasma glucose. We determined cardiometabolic risk factors in adolescents using age-appropriate cut-off points. We calculated odds ratios (OR) and 95% confidence intervals (CI) of these outcomes associated with having prediabetes compared with normal glucose levels. RESULTS: The weighted prevalence of prediabetes was 17.4%. After adjustment, prediabetes (vs. normal glucose) was associated with obesity (OR 1.86, 95% CI 1.35-2.55), low HDL-cholesterol (OR 1.62, 95% CI 1.08-2.44), high triglycerides (OR 1.61, 95% CI 1.12-2.30) and elevated liver transaminase (OR 2.09, 95% CI 1.19-3.67), but not with hypertension (OR 1.77, 95% CI 0.88-3.54), elevated total cholesterol (OR 1.30, 95% CI 0.82-2.06), elevated LDL-cholesterol (OR 1.59, 95% CI 0.88-2.88) or albuminuria (OR 1.24, 95% CI 0.76-2.02). CONCLUSIONS: US adolescents with prediabetes are more likely to have obesity, low HDL-cholesterol, high triglycerides and elevated liver transaminase than adolescents with normal glucose. Addressing prediabetes in youth is important for the prevention of Type 2 diabetes and long-term comorbidity.

Trends in dietary intake among adults with type 2 diabetes: NHANES 1988-2012.

BACKGROUND: Dietary recommendations for adults with diabetes are to follow a healthy diet in appropriate portion sizes. We determined recent trends in energy and nutrient intakes among a nationally representative sample of US adults with and without type 2 diabetes. METHODS: Participants were adults aged ≥20 years from the cross-sectional National Health and Nutrition Examination Surveys, 1988-2012 (N = 49 770). Diabetes was determined by self-report of a physician's diagnosis (n = 4885). Intake of energy and nutrients were determined from a 24-h recall by participants of all food consumed. Linear regression was used to test for trends in mean intake over time for all participants and by demographic characteristics. RESULTS: Among adults with diabetes, overall total energy intake increased between 1988-1994 and 2011-2012 (1689 kcal versus 1895 kcal; Ptrend < 0.001) with evidence of a plateau between 2003-2006 and 2011-2012. In 2007-2012, energy intake was greater for younger than older adults, for men than women, and for non-Hispanic whites versus non-Hispanic blacks. There was no change in the percentage of calories from carbohydrate, total fat or protein. Percentage of calories from saturated fat was similar across study periods but remained above recommendations (11.2% in 2011-2012). Fibre intake significantly decreased and remained below recommendations (Ptrend = 0.002). Sodium, cholesterol and calcium intakes increased. There was no change in energy intake among adults without diabetes and dietary trends were similar to those with diabetes. CONCLUSIONS: Future data are needed to confirm a plateau in energy intake among adults with diabetes, although the opportunity exists to increase fibre and reduce saturated fat.

Hormone replacement therapy and glucose metabolism.

OBJECTIVE: To determine whether hormone replacement therapy (HRT) alters glucose metabolism. METHODS: Cross-sectional data from the third National Health and Nutrition Examination Survey (1988-1994) included levels of hemoglobin A(1c) in women with diagnosed diabetes and levels of hemoglobin A(1c), fasting and 2-hour glucose, and fasting insulin and C-peptide in women without diagnosed diabetes. We compared mean values for these measures among never, current, and past users of HRT with adjustment for confounders. Types of hormones were not studied. RESULTS: Hormone replacement therapy was used by 8. 6% of diabetic women and 16.7% of women without diagnosed diabetes; 19.3% and 18.5%, respectively, had used HRT in the past. Current use approximately doubled among diabetic women between 1988-1991 and 1991-1994. Current users had lower hemoglobin A(1c) and fasting plasma glucose levels but higher 2-hour glucose levels compared with never and past users. After adjustment for confounding factors, hemoglobin A(1c) levels were 0.1% lower, fasting glucose levels were 3 mg/dL lower, and 2-hour glucose levels were 15 mg/dL higher in current users. Fasting serum insulin and C-peptide levels were not associated with HRT use. Duration of HRT use among current users and time since cessation among former users were not associated with measures of glucose metabolism. CONCLUSION: The prevalence of HRT in the United States among diabetic women is approximately half that of women without diabetes diagnoses, although it appears to be increasing. Postmenopausal hormones appear to have no adverse effect on basal glucose metabolism but are associated with slightly elevated postchallenge glucose levels.

Oral contraceptive use and glucose metabolism in a national sample of women in the united states.

OBJECTIVE: This study was undertaken to determine whether users of oral contraceptives in a nationally representative population of US women had elevated levels of measures of glucose metabolism. STUDY DESIGN: Cross-sectional data from the Third National Health and Nutrition Examination Survey (1988-1994) included hemoglobin A(1c) levels and fasting glucose, insulin, and C-peptide levels. Means were compared among those who had never used oral contraceptives, current users of oral contraceptives, and former users of oral contraceptives, with and without adjustment for potential confounders. RESULTS: The vast majority of current users of oral contraceptives were using low-dose estrogen formulations. The two most common preparations were a triphasic formulation containing 0. 035 mg ethinyl estradiol and 0.5, 0.75, and 1 mg norethindrone (23. 9%) and a monophasic formulation containing 0.035 ethinyl estradiol and 1 mg norethindrone (20.7%). Current users of oral contraceptives did not have elevated values for any of the four measures of glucose metabolism. Hemoglobin A(1c) level and fasting glucose, insulin, and C-peptide levels were not related to duration of current use, age at which use began, or major formulation type. Among women who were former users of oral contraceptives there was no evidence of higher values among those who had recently ceased use. CONCLUSION: Oral contraceptive formulations currently available in the United States are not associated with an adverse glucose metabolic profile.

Diurnal variation in fasting plasma glucose: implications for diagnosis of diabetes in patients examined in the afternoon.

CONTEXT: Current diagnostic criteria for diabetes are based on plasma glucose levels in blood samples obtained in the morning after an overnight fast, with a value of 7.0 mmol/L (126 mg/dL) or more indicating diabetes. However, many patients are seen by their physicians in the afternoon. Because plasma glucose levels are higher in the morning, it is unclear whether these diagnostic criteria can be applied to patients who are tested for diabetes in the afternoon. OBJECTIVES: To document diurnal variation in fasting plasma glucose levels in adults not known to have diabetes, and to examine the applicability to afternoon-examined patients of the current diagnostic criteria for diabetes. DESIGN, SETTING, AND PARTICIPANTS: Analysis of data from the US population-based Third National Health and Nutrition Examination Survey (1988-1994) on participants aged 20 years or older who had no previously diagnosed diabetes, who were randomly assigned to morning (n = 6483) or afternoon (n = 6399) examinations, and who fasted prior to blood sampling. MAIN OUTCOME MEASURES: Fasting plasma glucose levels in morning vs afternoon-examined participants; diabetes diagnostic value for afternoon-examined participants. RESULTS: The morning and afternoon groups did not differ in age, body mass index, waist-to-hip ratio, physical activity index, glycosylated hemoglobin level, and other factors. Mean (SD) fasting plasma glucose levels were higher in the morning group (5.41 [0.01] mmol/L [97.4 ¿0.3¿ mg/dL]) than in the afternoon group (5.12 [0.02] mmol/L [92.4 ¿0.4¿ mg/dL]; P<.001). Consequently, prevalence of afternoon-examined participants with fasting plasma glucose levels of 7.0 mmol/L (126 mg/dL) or greater was half that of participants examined in the morning. The diagnostic fasting plasma glucose value for afternoon-examined participants that resulted in the same prevalence of diabetes found in morning-examined participants was 6.33 mmol/L (114 mg/dL) or greater. CONCLUSIONS: Our results indicate that if current diabetes diagnostic criteria are applied to patients seen in the afternoon, approximately half of all cases of undiagnosed diabetes in these patients will be missed.

Diabetes and decline in heart disease mortality in US adults.

CONTEXT: Mortality from coronary heart disease has declined substantially in the United States during the past 30 years. However, it is unknown whether patients with diabetes have also experienced a decline in heart disease mortality. OBJECTIVE: To compare adults with diabetes with those without diabetes for time trends in mortality from all causes, heart disease, and ischemic heart disease. DESIGN, SETTING, AND PARTICIPANTS: Representative cohorts of subjects with and without diabetes were derived from the First National Health and Nutrition Examination Survey (NHANES I) conducted between 1971 and 1975 (n = 9639) and the NHANES I Epidemiologic Follow-up Survey conducted between 1982 and 1984 (n = 8463). The cohorts were followed up prospectively for mortality for an average of 8 to 9 years. MAIN OUTCOME MEASURE: Changes in mortality rates per 1000 person-years for all causes, heart disease, and ischemic heart disease for the 1982-1984 cohort compared with the 1971-1975 cohort. RESULTS: For the 2 periods, nondiabetic men experienced a 36.4% decline in age-adjusted heart disease mortality compared with a 13.1% decline for diabetic men. Age-adjusted heart disease mortality declined 27% in nondiabetic women but increased 23% in diabetic women. These patterns were also found for all-cause mortality and ischemic heart disease mortality. CONCLUSIONS: The decline in heart disease mortality in the general US population has been attributed to reduction in cardiovascular risk factors and improvement in treatment of heart disease. The smaller declines in mortality for diabetic subjects in the present study indicate that these changes may have been less effective for people with diabetes, particularly women.

Racial and ethnic differences in glycemic control of adults with type 2 diabetes.

OBJECTIVE: To evaluate glycemic control in a representative sample of U.S. adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: The Third National Health and Nutrition Examination Survey included national samples of non-Hispanic whites, non-Hispanic blacks, and Mexican Americans aged > or = 20 years. Information on medical history and treatment of diabetes was obtained to determine those who had been diagnosed with type 2 diabetes by a physician before the survey (n = 1,480). Fasting plasma glucose and HbA1c were measured, and the frequencies of sociodemographic and clinical variables related to glycemic control were determined. RESULTS: A higher proportion of non-Hispanic blacks were treated with insulin and a higher proportion of Mexican Americans were treated with oral agents compared with non-Hispanic whites, but the majority of adults in each racial or ethnic group (71-83%) used pharmacologic treatment for diabetes. Use of multiple daily insulin injections was more common in whites. Blood glucose self-monitoring was less common in Mexican Americans, but most patients had never self-monitored. HbA1c values in the nondiabetic range were found in 26% of non-Hispanic whites, 17% of non-Hispanic blacks, and 20% of Mexican Americans. Poor glycemic control (HbA1c > 8%) was more common in non-Hispanic black women (50%) and Mexican-American men (45%) compared with the other groups (35-38%), but HbA1c for both sexes and for all racial and ethnic groups was substantially higher than normal levels. Those with HbA1c > 8% included 52% of insulin-treated patients and 42% of those taking oral agents. There was no relationship of glycemic control to socioeconomic status or access to medical care in any racial or ethnic group. CONCLUSIONS: These data indicate that many patients with type 2 diabetes in the U.S. have poor glycemic control, placing them at high risk of diabetic complications. Non-Hispanic black women, Mexican-American men, and patients treated with insulin and oral agents were disproportionately represented among those in poor glycemic control. Clinical, public health, and research efforts should focus on more effective methods to control blood glucose in patients with diabetes.

Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study.

OBJECTIVE: To compare the risk for diabetic retinopathy in non-Hispanic white, non-Hispanic black, and Mexican-American adults with type 2 diabetes in the U.S. population. RESEARCH DESIGN AND METHODS: Representative population-based samples of people aged > or = 40 years in each of the three racial/ethnic groups were studied in the 1988-1994. Third National Health and Nutrition Examination Survey (NHANES III). Diagnosed diabetes was ascertained by medical history interview, and undiagnosed diabetes by measurement of fasting plasma glucose. A fundus photograph of a single eye was taken with a nonmydriatic camera, and a standardized protocol was used to grade diabetic retinopathy. Information on risk factors for retinopathy was obtained by interview and standard laboratory procedures. RESULTS: Prevalence of any lesions of diabetic retinopathy in people with diagnosed diabetes was 46% higher in non-Hispanic blacks and 84% higher in Mexican Americans, compared with non-Hispanic whites. Blacks and Mexican Americans also had higher rates of moderate and severe retinopathy and higher levels of many putative risk factors for retinopathy. Blacks had lower retinopathy prevalence among those with undiagnosed diabetes. In logistic regression, retinopathy in people with diagnosed diabetes was associated only with measures of diabetes severity (duration of diabetes, HbA1c, level, treatment with insulin and oral agents) and systolic blood pressure. After adjustment for these factors, the risk of retinopathy in Mexican Americans was twice that of non-Hispanic whites, but non-Hispanic blacks were not at higher risk for retinopathy. These risks were similar when people with undiagnosed diabetes were included in the logistic regression models. CONCLUSIONS: The prevalence and severity of diabetic retinopathy is greater in non-Hispanic blacks and Mexican Americans with type 2 diabetes in the U.S. population than in non-Hispanic whites. For blacks, this can be attributed to their higher levels of risk factors for retinopathy, but the excess risk in Mexican Americans is unexplained.

Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993.

OBJECTIVE: To examine 22-year mortality (1971-1993), causes of death, life expectancy, and survival in a national sample of diabetic and nondiabetic adults according to age, sex, and race. RESEARCH DESIGN AND METHODS: A representative national cohort of 14,374 adults aged 25-74 years was identified in 1971-1975 in the First National Health and Nutrition Examination Survey (NHANES I). Diabetes was ascertained by medical history interview. The cohort was followed for mortality through 1992-1993, with verification of vital status for 96.2% (n = 13,830). Causes of death were determined from death certificates. RESULTS: Diabetic subjects comprised 5.1% of the cohort and accounted for 10.6% of the deaths. Mortality for diabetic subjects increased from 12.4 per 1,000 person-years for those aged 25-44 years at baseline to 89.7 per 1,000 person-years for those aged 65-74 years. The age-adjusted mortality rate was 57% higher for diabetic men than for diabetic women; the rate was 27% higher for diabetic non-Hispanic blacks than for diabetic non-Hispanic whites. Mortality rates were highest for insulin-treated subjects and for those with > or = 15 years' duration of diabetes. Diabetes was listed on the death certificate as the underlying cause of death for only 7.7% of diabetic men and 13.4% of diabetic women. Considering multiple causes of death, heart disease was listed the most frequently and was present on 69.5% of death certificates of people with diabetes. Death rates were higher for diabetic than for nondiabetic subjects in all age, sex, and race groups. The relative risk of death (diabetic versus nondiabetic subjects) declined with age from a value of 3.6 for those aged 25-44 years at baseline to 1.5 for those aged 65-74 years. The relative risk was elevated in diabetic subjects for all major causes of death except malignant neoplasms. Survival of diabetic subjects was lower than that of nondiabetic subjects in all age, sex, and race groups. Median life expectancy was 8 years lower for diabetic adults aged 55-64 years and 4 years lower for those aged 65-74 years. CONCLUSIONS: In this representative national sample of adults, mortality rates were higher for diabetic men than for diabetic women and for diabetic blacks than for diabetic whites. The study confirms the substantially higher risk of death, lower survival, and lower life expectancy of diabetic adults compared with nondiabetic adults.

Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988-1994.

OBJECTIVE: To evaluate the prevalence and time trends for diagnosed and undiagnosed diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults by age, sex, and race or ethnic group, based on data from the Third National Health and Nutrition Examination Survey, 1988-1994 (NHANES III) and prior Health and Nutrition Examination Surveys (HANESs). RESEARCH DESIGN AND METHODS: NHANES III contained a probability sample of 18,825 U.S. adults > or = 20 years of age who were interviewed to ascertain a medical history of diagnosed diabetes, a subsample of 6,587 adults for whom fasting plasma glucose values were obtained, and a subsample of 2,844 adults between 40 and 74 years of age who received an oral glucose tolerance test. The Second National Health and Nutrition Examination Survey, 1976-1980, and Hispanic HANES used similar procedures to ascertain diabetes. Prevalence was calculated using the 1997 American Diabetes Association fasting plasma glucose criteria and the 1980-1985 World Health Organization (WHO) oral glucose tolerance test criteria. RESULTS: Prevalence of diagnosed diabetes in 1988-1994 was estimated to be 5.1% for U.S. adults > or = 20 years of age (10.2 million people when extrapolated to the 1997 U.S. population). Using American Diabetes Association criteria, the prevalence of undiagnosed diabetes (fasting plasma glucose > or = 126 mg/dl) was 2.7% (5.4 million), and the prevalence of impaired fasting glucose (110 to < 126 mg/dl) was 6.9% (13.4 million). There were similar rates of diabetes for men and women, but the rates for non-Hispanic blacks and Mexican-Americans were 1.6 and 1.9 times the rate for non-Hispanic whites. Based on American Diabetes Association criteria, prevalence of diabetes (diagnosed plus undiagnosed) in the total population of people who were 40-74 years of age increased from 8.9% in the period 1976-1980 to 12.3% by 1988-1994. A similar increase was found when WHO criteria were applied (11.4 and 14.3%). CONCLUSIONS: The high rates of abnormal fasting and postchallenge glucose found in NHANES III, together with the increasing frequency of obesity and sedentary lifestyles in the population, make it likely that diabetes will continue to be a major health problem in the U.S.

Comparison of diabetes diagnostic categories in the U.S. population according to the 1997 American Diabetes Association and 1980-1985 World Health Organization diagnostic criteria.

OBJECTIVE: To compare the 1997 American Diabetes Association (ADA) and the 1980-1985 World Health Organization (WHO) diagnostic criteria in categorization of the diabetes diagnostic status of adults in the U.S. RESEARCH DESIGN AND METHODS: Analyses are based on a probability sample of the U.S. population age 40-74 years in the 1988-1994 Third National Health and Nutrition Examination Survey (NHANES III). People with diabetes diagnosed before the survey were identified by questionnaire. For 2,844 people without diagnosed diabetes, fasting plasma glucose was obtained after an overnight 9 to < 24-h fast, HbA1c was measured, and a 2-h oral glucose tolerance test was administered. RESULTS: Prevalence of diagnosed diabetes in this age-group is 7.9%. Prevalence of undiagnosed diabetes is 4.4% by ADA criteria and 6.4% by WHO criteria. The net change of -2.0% occurs because 1.0% are classified as having undiagnosed diabetes by ADA criteria but have impaired or normal glucose tolerance by WHO criteria, and 3.0% are classified as having impaired fasting glucose or normal fasting glucose by ADA criteria but have undiagnosed diabetes by WHO criteria. Prevalence of impaired fasting glucose is 10.1% (ADA), compared with 15.6% for impaired glucose tolerance (WHO). For those with undiagnosed diabetes by ADA criteria, 62.1% are above the normal range for HbA1c compared with 47.1% by WHO criteria. Mean HbA1c is 7.07% for undiagnosed diabetes by ADA criteria and 6.58% by WHO criteria. CONCLUSIONS: The number of people with undiagnosed diabetes by ADA criteria is lower than that by WHO criteria. However, those individuals classified by ADA criteria are more hyperglycemic, with higher HbA1c values and a greater proportion of values above the normal range. This fact, together with the simplicity of obtaining a fasting plasma glucose value, may result in the detection of a greater proportion of people with undiagnosed diabetes in clinical practice using the new ADA diagnostic criteria.

Model of complications of NIDDM. I. Model construction and assumptions.

OBJECTIVE: To develop a model of NIDDM for analyzing prevention strategies for NIDDM. RESEARCH DESIGN AND METHODS: A Markov type model with Monte Carlo techniques was used. Age, sex, and ethnicity of cohort was based on U.S. data. Incidence rates of complications were also based on community and population studies. RESULTS: Nonproliferative retinopathy, proliferative retinopathy, and macular edema are predicted in 79, 19, and 52%, respectively, of people with NIDDM; 19% are predicted to develop legal blindness. Microalbuminuria, gross proteinuria, and end-stage renal disease related to diabetes are predicted in 53, 40, and 17%, respectively. Symptomatic sensorimotor neuropathy and lower-extremity amputation are predicted in 31 and 17%, respectively. Cardiovascular disease is predicted in 39%. Higher rates of complications (1.1-3.0x) are predicted in minority populations. Predicted average life expectancy is 17 years after diagnosis. CONCLUSIONS: A probabilistic model of NIDDM predicts the vascular complications of NIDDM in a cohort representative of the incident cases of diabetes in the U.S. before age 75 years. Predictions of complications and mortality are consistent with the known epidemiology of NIDDM. The model is suitable for evaluating the effect of preventive interventions on the natural history of NIDDM.

Ambulatory medical care for non-Hispanic whites, African-Americans, and Mexican-Americans with NIDDM in the U.S.

OBJECTIVE: To assess whether medical care for diabetes is different among non-Hispanic whites, African-Americans, and Mexican-Americans with NIDDM. RESEARCH DESIGN AND METHODS: A questionnaire was administered to a representative U.S. sample of 2,170 noninstitutionalized adults with NIDDM. Information was obtained on physician visits, hyperglycemic therapy, monitoring of glycemic control, screening for and monitoring of complications, and diabetes education. RESULTS: About 90% of subjects had a regular diabetes physician, and the physician visit rate was similar by race (median of four visits per year). African-Americans were more likely to be treated with insulin (51.9%) than non-Hispanic whites (35.9%, P < 0.0001) and Mexican-Americans (46.2%). Among insulin-treated subjects, African-Americans were less likely to use multiple daily insulin injections (35.1 vs. 53.8% of non-Hispanic whites [P < 0.0001] and 50.5% of Mexican-Americans [P = 0.027]) and were less likely to self-monitor their blood glucose at least once per day (14.0 vs. 29.8% of non-Hispanic whites [P < 0.0001] and 29.0% of Mexican-Americans). The rates of visits to specialists for diabetes complications, physician testing of blood glucose, and screening for hypertension, retinopathy, and foot problems were not substantially different among the three race/ethnic groups. A higher proportion of African-Americans (43.3%) than non-Hispanic whites (31.5%, P < 0.0001) and Mexican-Americans (25.6%, P = 0.001) had received patient education; however, the median number of hours of instruction was lower for African-Americans. CONCLUSIONS: The frequency of diabetes care is similar among non-Hispanic whites, African-Americans, and Mexican-Americans. The major differences relate to methods of glycemic control and patient education.

Frequency and determinants of screening for diabetes in the U.S.

OBJECTIVE: To determine the prevalence of risk factors for non-insulin-dependent diabetes mellitus (NIDDM) and the frequency of screening for NIDDM in U.S. adults. RESEARCH DESIGN AND METHODS: A detailed questionnaire was administered to a representative sample of 19,680 adults > or = 18 years of age who reported no medical history of diabetes in the 1989 National Health Interview Survey (NHIS). Information was obtained on risk factors for diabetes, complications related to diabetes, and whether the subjects had been screened for diabetes in the past year. Women reporting pregnancy in the past year were excluded from analysis. The prevalence of undiagnosed NIDDM according to the frequency of risk factors for NIDDM was determined based on oral glucose tolerance data from the National Health and Nutrition Examination Survey (NHANES) II and Hispanic Health and Nutrition Examination Survey (HHANES). RESULTS: Prevalence of undiagnosed NIDDM based on the NHANES II and HHANES increased with age, obesity, and family history of diabetes, reaching 11.7% in people with all three risk factors. Based on the NHIS, 77.5% of U.S. adults with no medical history of diabetes (131 million people) had at least one risk factor for NIDDM or complication related to NIDDM, and 22.9% (38 million people) had three or more risk factors or complications. Approximately 31% of adults reported being screened for diabetes in the past year. Screening rates increased with an increasing number of risk factors, but even among those with three risk factors, only 38.6% were screened for NIDDM. CONCLUSIONS: More than 7 million U.S. adults have undiagnosed NIDDM. Nevertheless, screening for diabetes in high-risk groups occurs substantially less frequently than necessary to detect undiagnosed NIDDM and institute appropriate hypoglycemic treatment.

Serum lipoproteins in African Americans and whites with non-insulin-dependent diabetes in the US population.

BACKGROUND: Despite the significant role that dyslipidemia is believed to play in the development of cardiovascular disease in diabetes, most studies examining diabetic dyslipidemia in the United States have not been population based, and very little data are available for African Americans with diabetes. We used data from a national survey to compare the effect of diabetes on lipid concentrations in African-American and white men and women. In addition, we examined other factors related to lipid concentrations and controlled for these factors in our analyses. METHODS AND RESULTS: The Second National Health and Nutrition Examination Survey included a representative sample of 4177 African Americans and whites in the US civilian noninstitutionalized population 20 to 74 years old. These persons were classified as having non-insulin-dependent diabetes mellitus (NIDDM) (n = 720) or as being nondiabetic (n = 3457) based on an oral glucose tolerance test and a medical history of diabetes. Subjects were given an interview and physical examination that included measurement of serum lipoproteins, body mass index, body fat distribution, dietary fat intake, alcohol consumption, frequency of smoking, and use of medications. By univariate analysis, a worse profile of mean cholesterol, triglycerides, and high-density lipoprotein cholesterol levels was generally apparent in NIDDM than in nondiabetic subjects, regardless of race or sex; a similar pattern was found for the prevalence of abnormal concentrations of these lipids. Lipid profiles appeared to be worse in whites with NIDDM than in African Americans. For mean total and low-density lipoprotein cholesterol, concentrations tended to be worse in women with NIDDM than in men. When other factors significantly affecting lipid levels were adjusted by multivariate analysis, we found that in all race/sex groups, total cholesterol was higher in NIDDM than in nondiabetic subjects but differences were not significant (P = 54), triglyceride concentrations were significantly higher in NIDDM subjects (P < .0001), and high-density lipoprotein cholesterol concentrations were lower in NIDDM subjects (P = .003). An interaction of diabetes with race was found for low-density lipoprotein cholesterol (P = .0001), where concentrations were substantially lower in NIDDM than in nondiabetic subjects among African Americans (P < .01) but slightly higher in NIDDM subjects among whites (P = .33). For other lipids, no differential effect of NIDDM was found by race or sex. CONCLUSIONS: In African-American and white men and women in the United States, NIDDM is associated with a pattern of dyslipidemia that may potentiate the atherosclerotic process. Diabetic treatment should include aggressive treatment of dyslipidemia to reduce this increased risk.

Differences in survival between black and white patients with diabetic end-stage renal disease.

OBJECTIVE: To evaluate whether the longer survival of blacks with diabetic end-stage renal disease (ESRD) relative to whites is due to racial differences in type of diabetes, comorbidity at ESRD onset, and ESRD treatment modality and to examine whether survival differences between blacks and whites occur only in certain population subgroups. RESEARCH DESIGN AND METHODS: The Michigan Kidney Registry was used to ascertain all blacks and whites (n = 594) with diabetic ESRD in southeastern Michigan, with ESRD onset at age < 65 years during 1974-1983. Patients were followed through 1988. Medical records were abstracted for type of diabetes, comorbidity at ESRD onset, and other factors. RESULTS: Median survival among insulin-dependent diabetes mellitus patients was 27 months in blacks and 17 months in whites, and among non-insulin-dependent diabetes mellitus patients was 30 months in blacks and 16 months in whites. After adjustment for confounding factors by Cox proportional hazards analysis, the death rate was 45% lower in blacks than in whites on dialysis (relative death rate [RDR] = 0.55, 95% confidence interval [CI] = 0.44-0.69), but was similar in blacks and whites with a renal transplant (RDR = 0.99, 95% CI = 0.64-1.52). Compared with dialysis, transplantation was associated with lower mortality in both races (white, RDR = 0.50, 95% CI = 0.36-0.70; blacks, RDR = 0.89, 95% CI = 0.60-1.34), although the effect was not statistically significant in blacks. Racial differences in survival did not vary by type of diabetes or any additional factor. CONCLUSIONS: Survival after ESRD onset is longer in blacks than in whites treated with dialysis, even after adjusting for comorbidity and other factors that affect survival. Survival does not differ by race among transplant patients.

Health-insurance coverage for adults with diabetes in the U.S. population.

OBJECTIVE: To compare the extent and types of health insurance coverage for adults with diabetes to coverage for those without diabetes in the U.S. population. RESEARCH DESIGN AND METHODS: Nationally representative samples of 2,405 adults with diabetes and 20,131 adults who were not known to have diabetes in the U.S. completed a questionnaire on current health insurance, including coverage through Medicare, private insurance, the military, and Medicaid and other public programs. RESULTS: Among all adults with diabetes, 92.0% have some form of health insurance, including 86.5% of those 18-64 years of age and 98.8% of those > or = 65 years of age. Approximately 41% are covered by more than one health insurance mechanism, but almost 600,000 people with diabetes do not have any form of health-care coverage. Little difference was found by type of diabetes in the proportion who have health insurance. Only small differences exist between people with diabetes and those without diabetes in the percentages covered and the types of health-care coverage. Government-funded programs are responsible for health-care coverage of 57.4% of adults with diabetes, including 26.4% of those 18-64 years of age and 96.0% of those > or = 65 years of age. Private health insurance is held by 69.3% of diabetic people. Lack of private insurance appears to be attributable primarily to lower income. CONCLUSIONS: Almost all patients with diabetes who are > or = 65 years of age have health-care coverage, but 13.5% of those 18-64 years of age have no health insurance. Few differences exist in coverage between individuals with and without diabetes. However, the absence of insurance should have a substantially greater impact on the ability of patients with diabetes to obtain services necessary for care of their disease, compared with those without diabetes. Government-funded insurance mechanisms cover a large proportion of diabetic patients, which indicates a significant societal burden associated with diabetes. Any changes in government reimbursement and coverage policies could have a major impact on health care for patients with diabetes.

Ophthalmic examination among adults with diagnosed diabetes mellitus.

OBJECTIVE: To assess whether adults with diagnosed diabetes in the United States are receiving recommended eye examinations for detection of diabetic retinopathy and what factors are associated with receiving them. DESIGN, SETTING, AND PARTICIPANTS: The design was a cross-sectional survey of the civilian, noninstitutionalized US population 18 years of age or older, based on the 1989 National Health Interview Survey. A multistage probability sampling strategy was used to identify a representative sample of 84,572 persons. A questionnaire on diabetes was administered to all subjects with diagnosed diabetes (n = 2405). MAIN OUTCOME MEASURE: A dilated eye examination in the past year. MAIN RESULTS: Of all adults with diagnosed diabetes in the United States, only 49% had a dilated eye examination in the past year. This included 57% of people with insulin-dependent diabetes mellitus (IDDM), 55% with insulin-treated non-insulin-dependent diabetes mellitus (NIDDM), and 44% with NIDDM not treated with insulin. Even among diabetics at high risk of vision loss because of retinopathy or long duration of diabetes, the proportion with a dilated eye examination was only 61% and 57%, respectively. By logistic regression, the probability of a dilated eye examination among persons with NIDDM increased with older age, higher socioeconomic status, and having attended a diabetes education class. The probability of a dilated eye examination was not independently related to race, duration of diabetes, frequency of physician visits for diabetes, or health insurance. CONCLUSIONS: About half of adults with diabetes in the United States are not receiving timely and recommended eye care to detect and treat retinopathy. Widespread interventions, including patient and professional education, are needed to ensure that diabetic patients who are not receiving appropriate eye care have an annual dilated eye examination to detect retinopathy and prevent vision loss.

Diabetic renal disease: racial and ethnic differences from an epidemiologic perspective.

In summary, Native Americans, Hispanics, and blacks are at higher risk of diabetic ESRD relative to whites, particularly among subjects with NIDDM, even after controlling for the higher prevalence of diabetes in these groups. Incidence of diabetic ESRD is increasing in all race and ethnic groups, particularly in Native Americans and Hispanics. This increase may be real or artifactual. Based on the results of a few studies, controlling for several risk factors for diabetic ESRD does not explain the excess risk in blacks and Hispanics. Survival after beginning treatment for diabetic ESRD is longer in blacks, Native Americans, and Asian/Pacific Islanders when compared to whites. Longer survival in blacks compared with whites occurs among dialysis patients, but not in transplant patients, after controlling for type of diabetes and comorbidity present at onset of ESRD. The higher incidence of diabetic ESRD in blacks, Hispanics, and Native Americans, combined with an increased incidence over time and longer survival after ESRD onset, indicate that these racial and ethnic groups will comprise a large portion of diabetic ESRD in the future.